Assessment of the learning curve for EUS-guided gastroenterostomy for a single operator

Published:September 25, 2020DOI:https://doi.org/10.1016/j.gie.2020.09.041

      Background and Aims

      EUS-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative to surgery and enteral stent placement to manage gastric outlet obstruction (GOO). However, no data are available on the learning curve (LC) for EUS-GE. Defining the LC is necessary to create adequate subspecialty training programs and quality assurance.

      Methods

      This study is a retrospective analysis of a prospectively maintained dataset of patients who underwent EUS-GE at 1 tertiary referral center. Primary outcome was the LC for EUS-GE defined by the number of cases needed to achieve proficiency and mastery using cumulative sum (CUSUM) analysis. Moving average graphs and sequential time-block analysis were also performed to assess procedural time. Secondary outcomes included efficacy and safety of EUS-GE.

      Results

      Eighty-seven consecutive patients underwent EUS-GE, mostly for malignant GOO. For consistency, 14 patients were excluded from analysis (noncautery-assisted EUS-GE, 11; surgical anatomy, 3). The same endoscopist performed all procedures using the same freehand technique. Technical success was achieved in 68 of 73 patients (93%). Immediate adverse events occurred in 4 patients (5.5%), whereas late adverse events occurred only in 1 patient (1%), all managed conservatively or endoscopically. All immediate adverse events occurred during the first 39 cases. Clinical success (defined as resuming at least an oral liquid diet within a week) was achieved in 97% of patients. The mean procedural time was 36 minutes (standard deviation, 24). Evaluation of the CUSUM curve revealed that 25 cases were needed to achieve proficiency and 40 cases to achieve mastery. These results were confirmed with the average moving curve and sequential time-block analysis.

      Conclusions

      We report, for the first time, data on the LC for EUS-GE. About 25 procedures can be considered as the threshold to achieve proficiency and about 40 cases are needed to reach mastery of the technique.

      Abbreviations:

      AE (adverse event), CUSUM (cumulative sum), EUS-GE (EUS-guided gastroenterostomy), GOO (gastric outlet obstruction), LAMS (lumen-apposing metal stent), LC (learning curve)
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      References

        • Medina-Franco H.
        • Abarca-Pérez L.
        • España-Gómez N.
        • et al.
        Morbidity-associated factors after gastrojejunostomy for malignant gastric outlet obstruction.
        Am Surg. 2007; 73: 871-875
        • Dormann A.
        • Meisner S.
        • Verin N.
        • et al.
        Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness.
        Endoscopy. 2004; 36: 543-550
        • Jeurnink S.M.
        • Steyerberg E.W.
        • van Hooft J.E.
        • et al.
        Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial.
        Gastrointest Endosc. 2010; 71: 490-499
        • Khashab M.
        • Alawad A.S.
        • Shin E.J.
        • et al.
        Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction.
        Surg Endosc. 2013; 27: 2068-2075
        • Fukami N.
        • Anderson M.A.
        • Khan K.
        • et al.
        • ASGE Standards of Practice Committee
        The role of endoscopy in gastroduodenal obstruction and gastroparesis.
        Gastrointest Endosc. 2011; 74: 13-21
        • Carbajo A.Y.
        • Kahaleh M.
        • Tyberg A.
        Clinical review of EUS-guided gastroenterostomy (EUS-GE).
        J Clin Gastroenterol. 2020; 54: 1-7
        • Binmoeller K.F.
        • Shah J.N.
        Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study.
        Endoscopy. 2012; 44: 499-503
        • Khashab M.A.
        • Kumbhari V.
        • Grimm I.S.
        • et al.
        EUS-guided gastroenterostomy: the first U.S. clinical experience (with video).
        Gastrointest Endosc. 2015; 82: 932-938
        • Itoi T.
        • Ishii K.
        • Ikeuchi N.
        • et al.
        Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction.
        Gut. 2016; 65: 193-195
        • Tyberg A.
        • Kumta N.
        • Karia K.
        • et al.
        EUS-guided gastrojejunostomy after failed enteral stenting.
        Gastrointest Endosc. 2015; 81: 1011-1012
        • Khashab M.A.
        • Tieu A.H.
        • Azola A.
        • et al.
        EUS-guided gastrojejunostomy for management of complete gastric outlet obstruction.
        Gastrointest Endosc. 2015; 82: 745
        • Ge P.S.
        • Young J.Y.
        • Dong W.
        • et al.
        EUS-guided gastroenterostomy versus enteral stent placement for palliation of malignant gastric outlet obstruction.
        Surg Endosc. 2019; 33: 3404-3411
        • Chen Y.-I.
        • Itoi T.
        • Baron T.H.
        • et al.
        EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction.
        Surg Endosc. 2017; 31: 2946-2952
        • Khashab M.A.
        • Bukhari M.
        • Baron T.H.
        • et al.
        International multicenter comparative trial of endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for the treatment of malignant gastric outlet obstruction.
        Endosc Int Open. 2017; 5: E275-E281
        • Perez-Miranda M.
        • Tyberg A.
        • Poletto D.
        • et al.
        EUS-guided gastrojejunostomy versus laparoscopic gastrojejunostomy: an international collaborative study.
        J Clin Gastroenterol. 2017; 51: 896-899
        • McCarty T.R.
        • Garg R.
        • Thompson C.C.
        • et al.
        Efficacy and safety of EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction: a systematic review and meta-analysis.
        Endosc Int Open. 2019; 7: E1474-E1482
        • Teoh A.Y.B.
        • Dhir V.
        • Kida M.
        • et al.
        Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel.
        Gut. 2018; 67: 1209-1228
        • Chen Y.I.
        • Kunda R.
        • Storm A.C.
        • et al.
        EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques.
        Gastrointest Endosc. 2018; 87: 1215-1221
        • Kerdsirichairat T.
        • Irani S.
        • Yang J.
        • et al.
        Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction.
        Endosc Int Open. 2019; 7: E144-E150
        • Irani S.
        • Itoi T.
        • Baron T.H.
        • et al.
        EUS-guided gastroenterostomy: techniques from East to West.
        VideoGIE. 2019; 5: 48-50
        • Novick R.J.
        • Stitt L.W.
        The learning curve of an academic cardiac surgeon: use of the CUSUM method.
        J Card Surg. 1999; 14 (discussion 321-2): 312-320
        • Van Rij A.M.
        • McDonald J.R.
        • Pettigrew R.A.
        • et al.
        Cusum as an aid to early assessment of the surgical trainee.
        Br J Surg. 1995; 82: 1500-1503
        • Liu Z.
        • Zhang X.
        • Zhang W.
        • et al.
        comprehensive evaluation of the learning curve for peroral endoscopic myotomy.
        Clin Gastroenterol Hepatol. 2018; 16: 1420-1426
        • Lv H.
        • Zhao N.
        • Zheng Z.
        • et al.
        Analysis of the learning curve for peroral endoscopic myotomy for esophageal achalasia: single-center, two-operator experience.
        Dig Endosc. 2017; 29: 299-306
        • Patel K.S.
        • Calixte R.
        • Modayil R.J.
        • et al.
        The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy.
        Gastrointest Endosc. 2015; 81: 1181-1187
        • Modayil R.
        • Stavropoulos S.N.
        How many peroral endoscopic myotomy procedures are necessary for proficiency?.
        Clin Gastroenterol Hepatol. 2018; 16: 1393-1397
        • Kurian A.A.
        • Dunst C.M.
        • Sharata A.
        • et al.
        Peroral endoscopic esophageal myotomy: defining the learning curve.
        Gastrointest Endosc. 2013; 77: 719-725
        • El Zein M.
        • Kumbhari V.
        • Ngamruengphong S.
        • et al.
        Learning curve for peroral endoscopic myotomy.
        Endosc Int Open. 2016; 4: E577-E582
        • Jovani M.
        • Ichkhanian Y.
        • Vosoughi K.
        • et al.
        EUS-guided biliary drainage for postsurgical anatomy.
        Endosc Ultrasound. 2019; 8: S57-S66
        • Yang D.
        • Wagh M.S.
        • Draganov P.V.
        The status of training in new technologies in advanced endoscopy: from defining competence to credentialing and privileging.
        Gastrointest Endosc. 2020; 92: 1016-1025
        • DiMaio C.J.
        • Mishra G.
        • McHenry L.
        • et al.
        • ASGE Training Committee
        EUS core curriculum.
        Gastrointest Endosc. 2012; 76: 476-481
        • Wani S.
        • Han S.
        • Simon V.
        • et al.
        Setting minimum standards for training in EUS and ERCP: results from a prospective multicenter study evaluating learning curves and competence among advanced endoscopy trainees.
        Gastrointest Endosc. 2019; 89: 1160-1168

      Linked Article

      • Learning curves for EUS: single operators, endoscopy teams, and institutions
        Gastrointestinal EndoscopyVol. 93Issue 4
        • Preview
          We read with interest the article by Jovani et al.1 The authors concluded that based on the performance of a single operator, proficiency and mastery for EUS-guided gastroenterostomy (EUS-GE) are achieved after 25 and 40 procedures, respectively. Another recently published single-operator study from a different institution reported that 7 EUS-GE cases were adequate to achieve efficiency.2 The adverse events from these 2 endoscopists showed discrepancy: 5.6% (4 of 73 cases) in Jovani et al1 versus 26% (6 of 23 cases) in Tyberg et al.
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      • EUS-guided gastroenterostomy: closing knowledge gaps by evaluating learning curves
        Gastrointestinal EndoscopyVol. 93Issue 5
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          Lumen-apposing metal stents (LAMSs) have greatly facilitated EUS-guided drainage in established and emerging indications. Off-label use of LAMSs to create various GI anastomoses has continued to evolve in parallel. This is in stark contrast with previous endoscopic techniques for the creation of GI anastomoses, which never gained clinical acceptance.1 EUS-guided GI anastomosis (EUS-GIA) by transmural placement of LAMSs was proved feasible in preclinical studies nearly a decade ago.1,2 After these seminal experiments, EUS-GIA was first used clinically to allow through-the-stent transluminal ERCP in Roux-en-Y hepaticojejunostomy3 and gastric bypass4 patients.
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        • PDF